Method and system for performing endoscopic surgery at locations where tissue inserts into bone

ABSTRACT

An endoscopic system and method for performing endoscopic surgery at locations where tissue inserts into bone which includes a sleeve member, obturator, cutting and excision instruments, and a marking and insertion assembly wherein the sleeve member has an expanded portal through which instrument access and improved visualization can be performed at arcuate lines of insertion of tissue into bone. The sleeve member can include a flange for engaging tissue along the line of insertion and exposing the bone and measurement means for gauging precisely the reduction or resection of bone. An alternative embodiment of the sleeve member has a non-uniform aperture with an instrument portion and a register portion providing increased space and maneuverability for instruments when operating at the portal on tissue or bone that can include the flange. Cutting instruments are provided with an extension portion to extravasate from tissue and palpitate underlying tissue. An marking and insertion assembly for use in heel surgeries to remedy plantar fasciitis and in conjunction with a lateral radiograph provides precise location of an entry incision and precise medial to lateral insertion of a guide wire forming a channel for the sleeve member. The method system also provides for minimum incision surgery in the caudal release of the plantar fascia and reduction of a spur on the os calcis.

This is a division of application Ser. No. 07/914,192 filed Jul. 14,1992 now U.S. Pat. No. 5,253,659.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to endoscopic surgery at locations in thebody where tissue inserts into bone and more particularly to a methodand system of performing endoscopic heel surgery.

2. Description of the Prior Art

Various techniques and systems for performing endoscopic surgery in thebody have been developed. These systems provide instrument access andvisualization of tissue targeted by a specific operation. Advances havebeen made at locations in the body where a natural channel or simplepathway can be formed by a tube having a slot or opening for identifyingand operating on the target tissue. However, at other locations in thebody these known methods and systems for endoscopic surgery haveproblems providing access and visualization at or near a line ofinsertion of tissue to bone. Problems occur because most bones have anarcuate surface with the corresponding line of insertion curving awayfrom the opening resulting in the diminished reach of an instrument andimaging of an endoscope. Other disadvantages of known systems includediminished visualization of deep cuts in thick tissues, the ability toidentify and operate on adjacent tissues often requiting repositioningof the tube. Furthermore, a repositioned tube may not provide the neededaccess or visualization of the specific operation. Repositioning hasother disadvantages including requiring additional surgical time andprocedures, larger incisions to maneuver the tube, and increasedlikelihood of damage to tissue or the like. Thus, the development ofmethod and system for use in endoscopic surgery of these arcuate bonesurfaces and lines of insertion without the disadvantages of knownmethods and systems would advance the state of the art.

In addition, these known endoscopic techniques and systems have notsolved problems of the particular environment of the bone and tissue inthe foot. As the human foot is the foundation for most movement, footpain and discomfort can cripple and seriously reduce such movement.Typically, adverse foot mechanisms coupled with factors such as obesityor various types of traumatic motion can lead to a painful heel syndromeor plantar fasciitis with or without a spur forming on the os calcis.The pain is located at a site where the plantar fascia inserts into theroedial and/or lateral tubercle of the os calcis. The insertion sitefollows an arcuate surface of the os calcis that may have a radialcomponent extending distally from both tubercles with a predilectiontowards the medial aspect of the foot. Problems arise because the footis formed from a complex web of compact tissue and bone underconsiderable tension with no available natural channel. Known endoscopictechniques have advocated forming a channel using sharp dissection orusing systems that visualize and blindly resect tissue from one end of atube. Each of these has the disadvantage of increasing the risk ofsevering vascular and neural structures around the heel.

Various non-endoscopic surgical techniques have been put forth torelieve the painful heel syndrome. Solutions have ranged from the use ofconservative measures such as orthotics to surgical intervention withvarying results depending upon the patient and other factors. Surgicalintervention includes forming large incisions at or around the heel,surgical exploration or dissection to reach the plantar fascia, releaseof the plantar fascia from the os calcis, and excision of thedegenerated fascia tissue and/or spur. Known methods of surgicalintervention have frequent sequela related to the interruption of theanatomy of the heel such as problems from the division of the roedialcalcaneal nerve causing foot numbness, protracted post operative painand discomfort, skin incision problems or painful scars on the bottomand roedial aspect of the foot, the inability to ambulate, as well asincomplete release of the plantar fascia due to inadequate visualizationof the operative site. Thus, a need exists for a simple heel surgerythat reduces surgical trauma without lengthening the recovery time.

Thus it is desirable to develop a method and system for endoscopicsurgeries targeting the insertion of tissue to bone that reduces thetrauma of surgical intervention. The system being able to overcomeproblems of the prior art to operate with greater precision than knownbefore to minimize scaring, damage to tissues, identify a plurality oftissue and bone structures, and release tissue and/or resect bone. Themethod and system should be adaptable to foot surgery with increasedsurgical precision, reduced trauma and damage to the vascular and neuralstructures for the remedy of plantar fasciitis such as in fasciotomies,fasciectomies, biopsies and resections of a spur on the os calcis. It isdesirable to form a system that can perform multiple operations andprocedures for the release of the plantar fascia and reduction of bonespurs that reduces recovery time and damage.

SUMMARY

Accordingly, it is an object of the present invention to provide amethod and system for endoscopic surgery at the insertion of tissue tobone that overcomes the many disadvantages of the prior art.

It is an object of the present invention to provide a method and systemfor endoscopic surgery tissue and bone of the heel that overcomes manyof the disadvantages of known surgical interventions.

An object of the present invention to provide a system of a simple andeasily operable construction being capable of use in the varioussurgical techniques for the remedy of plantar fasciitis.

It is another object of the present invention to provide a system andmethod for endoscopic surgery at the insertion of tissue into bone. Thesystem features an improved sleeve member with a portal configured forvisualization of the insertion of tissue to bone. In brief, the systemfor performing endoscopie surgery at the interface of tissue and boneusing a sleeve member formed from an elongated tube with open ends and aportal. The tube has slot segments extending inwardly from the open endsand the portal has edge portions interconnected to the slot segmentslocated at a midportion of the elongated tube. The portal forms anexpanded surgical site with the advantage of simultaneous access andvisualization of the interface of tissue and bone.

It is an object of the present invention to provide the portal with aflange to both push away and hold tissue during the resection of bone.

It is an object of the present invention to provide a sleeve memberwhere the portal has a measurement system for gauging the reduction of aspur to a desired dimension. The measurement system is advantageous foruse in measuring and improving the precision of the resection of tissueand/or bone.

It is another object of the present invention to provide an improvedsleeve member with a portal having instrument and register portionsconfigured for use in operations involving excision of a section or theplantar fascia.

It is an object of the present invention to provide improved cuttinginstruments for division of the plantar fascia with minimal trauma tothe underlying tissues. In brief, the instrument has an elongated shaftwith proximal and distal ends, a handle attached to the proximal end anda locking device for attaching the handle to the shaft. The distal endhas a rounded forward portion extending transverse from the shaft, acutting portion and an extension at the lower end of the cutting portionfor guiding between layers of tissue and palpitating tissue.

It is yet another object of the present invention to provide aninstrument for excision of a section of the plantar fascia with minimaltrauma to the underlying tissues. In brief, the excision instrument hasan elongated shaft with proximal and distal ends, a handle attached tothe proximal end and a locking device for attaching the handle to theshaft. The distal end has an operative portion provided with a cuttingsection and a gathering section. The cutting section has dual knivesextending transverse from the shaft forming a slot releasing a sectionof tissue. The knives are spaced apart and offset at an angle relativeto the longitudinal axis of the shaft. An extension at the lower end ofthe knives palpitates and guides between layers of tissue. The gatheringsection has a tooth means positioned within the slot for gathering andremoving a released section of tissue.

It is an object of the present invention to provide a system and methodof determination of entry and exit incision points in the heel forreducing damage to vascular and neural structures.

It is an object of the present invention to provide a marking system foruse with a lateral x-ray for precisely determining an entry incision.

It is yet another object of the present invention to provide aninsertion system for guiding a pin through the foot.

In brief, a procedure for performing endoscopic surgery in a patient torelieve a painful heel syndrome in a foot generally having a heel withskin, plantar fascia, vascular and neural structures, os calcis bone andmuscles including the flexor digitorum brevis, abductus digiti minimi,abductus hallucis. A location and mark for an entry incision isdetermined on a roedial side of the foot for avoiding the vascular andneural structures. Once the entry incision is made, a channel is formedbetween the os calcis, the plantar fascia, the aponulotic fibers of themuscles by bluntly separating the plantar fascia from surrounding softtissue both superiorly and inferiorly. The channel is formed to avoidthe vascular and neural structures in the heel using a detachableobturator and sleeve member assembly. The assembly is inserted anddriven from a roedial side to a lateral side of the foot until theassembly tents the skin on the lateral side where an exit incision ismade. The sleeve member and obturator are passed through to the lateralside of said foot to position and locate a portal of the sleeve memberat a predetermined operative site. The predetermined operative siteprovides simultaneous visualization of the plantar fascia, the os calcisand the line of insertion of the plantar fascia into the os calcis. Theobturator is retracted from the sleeve member forming a medial andlateral opening at each end of the sleeve member and leaving the sleevemember located at the predetermined operative site. An endoscope isinserted into the media opening and an instrument into in the lateralopening. One or more surgical operations are performed at the operativesite. The operative site is cleaned, the obturator is reinserted and theobturator and sleeve member retracted. The entry and exit incisions aresutured closed after successful performance of the desired surgicaloperations.

BRIEF DESCRIPTION OF THE DRAWING

These and other objects and advantages of the present invention willbecome readily apparent upon consideration of the following detaileddescription and attached drawing, wherein:

FIG. 1 is a elevational view illustrating the sleeve member for use inthe method and system for endoscopic heel surgery of the presentinvention;

FIG. 2 is a side view of the obturator assembly of the presentinvention;

FIG. 3, taken along lines 3--3 of FIG. 1, is a cross-sectional view ofthe sleeve member of the present invention;

FIG. 4, taken along lines 4--4 of FIG. 1, is a cross-sectional viewillustrating the stop member;

FIG. 5, taken along lines 5--5 of FIG. 2, is a cross-sectional view ofthe obturator and central bore;

FIG. 6 is an elevational view illustrating an additional embodiment thesleeve member of the present invention;

FIG. 7, is a cross-sectional view, taken along lines 7--7 of FIG. 6,illustrating the biopsy and endoscope portions of the present invention;

FIG. 8, is a side view illustrating an additional embodiment of theobturator of the present invention;

FIG. 9, is a cross-sectional view, taken along lines 9--9 of FIG. 8,illustrating the additional embodiment of the obturator of the presentinvention;

FIG. 10 is a side view illustrating a blunt tip of the obturator of FIG.8;

FIG. 11 is a perspective view illustrating a obturator and sleeve memberof an additional embodiment of the present invention;

FIG. 12 is an elevational view illustrating a sleeve member for yetanother embodiment of the present invention;

FIG. 13, taken along lines 13--13 of FIG. 12, illustrates a flange foruse in reduction of calcaneal spurs;

FIG. 14 is a side view illustrating an instrument for dividing theplantar fascia according to the present invention;

FIG. 15 is a side view illustrating another instrument for dividing theplantar fascia according to the present invention;

FIG. 16 is a schematic side view illustrating a handle configured toreceive an instrument according the present invention;

FIG. 17 is a schematic cross-sectional view, taken along lines 17--17 ofFIG. 16;

FIG. 18 is a side view illustrating another instrument for excision ofthe plantar fascia according to the present invention;

FIG. 19 is an end view illustrating the instrument of FIG. 18;

FIG. 20 is a plantar view of the foot illustrating the method forperforming endoscopic heel surgery according to the present invention;

FIGS. 21a and 21b are perspective side views of the foot illustratingthe placement of the system for endoscopic heel surgery according to themethod of the present invention;

FIG. 22 is a side view of the marking system according to the presentinvention;

FIG. 23 is an end view of the marking system in accordance with thepresent invention;

FIG. 24 is an elevational view and FIG. 24b is a schematiccross-sectional view of the insertion system of the present inventionand

FIG. 25 is an side view of the insertion system of the presentinvention; and

FIG. 26 is a is an end view of the insertion system of the presentinvention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

FIGS. 1-26, illustrate the preferred method and system of the presentinvention for the endoscopic release of the insertion of tissue intobone throughout the body. The present invention is described in theenvironment for treatment of the painful heel syndrome which can includeneuritis, myositis, faciitis and adventiteal bursiris with or without acalcaneal spur. The endoscopic release of the planar fascia at itsinsertion into the os calcis and/or resection of spurs has beensuccessful for relieving pain in the heel. The endoscopic system 20 ofthe present invention includes generally a cannula or sleeve member 22,trocar or obturator 24, fasciotomy instrument 110, excision instrument160 and a marking and insertion assembly 230. The sleeve member 22provides an expanded portal 44 through which multiple surgicalprocedures such as a fasciotomy, fasciectomy, biopsy and heel spurresection can be performed at actuate lines of insertion where tissueattaches to bone. Throughout the following detailed description,whenever possible the same reference numerals refer to like elements.

As illustrated in FIGS. 1, 3 and 4, the sleeve member 22 of the presentinvention includes an elongated tube 34 with open ends 36 and 38, andslot segments 40 and 42 extending inwardly from the open ends 36 and 38,respectively. A portal 44 is located at a mid portion of the sleevemember 22. The portal 44 is connected to slot segments 40 and 42 bytapper portions 46 to thus extend along the length of the elongated tube34. The portal 44 further includes side edge portions 48 and 50 to forman access 52 to view the heel structures such as the os calcis,neurovascular structures and plantar fascia. The access 52 allows anendoscope placed in, for example, open end 36 to form an image of theseheel structures. The access 52 also allows an instrument placed in theother open end 38 for surgical utilization on these heel structures. Theportal 44 can have width 56 determined by angle 58 so as to form anexpanded view of the insertion of the plantar fascia into the os calcisand other heel structures. The sleeve member 22 should be made to extendfrom either side of the foot, for example, having a length dimension of10 cm. The sleeve member 22 can be formed from suitable material such asnon-reflective plastic to improve endoscopic imaging and to allow forthe use of surgical lasers.

As shown in FIGS. 1, 2, 4 and 5, a collar or stop member 60 can beattached to end 36 of the sleeve member 22 to provide a grip whenmanipulating and as required for instruments or the like. The sleevemember 22 and stop member 60 are configured to slidably receiveobturator 24. The stop member 60 includes a guide 62 located on an innersurface 64 of the stop member 60. The guide 62 engages a stem 66 on theobturator 24. The guide 62 and stem 66 are assembled to interlock forinsertion into the heel and to indicate the alignment of the sleevemember 22. Recess points 68 on the exterior surface 70 of the stopmember 60 can be used advantageously for single handed gripping or forgripping with a ratchet (not shown) to rotate the portal 44 of sleevemember 22 into position adjacent the operative site. The stop member 60with tab portions 82 can interlock with nibble portions 84 adjacenteither open end 36 or 38 of the sleeve member 22. The obturator 24includes a generally smooth shaft 72 with blunt tapered distal end 74and handle 76 attached at the proximal end. The sleeve member 22slidably receives the shaft 72 along the length thereof with the bluntdistal end 74 protruding from end 38. In operation, the obturator 24 andsleeve member 22 are inserted through the foot with the portal 4,,positioned adjacent the insertion of the plantar fascia into the oscalcis. Alternatively, the obturator 24 can have a central bore 86 alongthe length of the shaft 72 for use in engaging a guide wire 248 of themarking and insertion assembly 230 as described herein and shown inFIGS. 24, 25 and 26.

FIGS. 6, 7, 8 and 9 illustrate an additional embodiment of the presentinvention. The sleeve member 54 is particularly useful in whenperforming a fasciectomy or excision of sections of the plantar fasciaand in biopsy of tissue. As best shown in FIG. 7, the sleeve member 54has a non-uniform cross-sectional aperture with an instrument portion 78and register portion 80. The larger dimension of the instrument portion78 increases the working area to accommodate excision or biopsyinstruments such as a rotary abrader, jaw-like forceps used in samplingtissue or other instruments. The register portion 80 can allow thesurgeon to hold the endoscope against the arcuate surface 88 as a meansfor steadying during resection of tissue or bone spurs using a raspinginstrument (not shown). The register portion 80 also provides increasedspace and maneuverability for instruments when operating on tissue orbone. As shown in FIG. 8, the shaft 72 of obturator 24 can be slidablyreceived in sleeve member 54 having upper protrusion 90 and lowerprotrusion 92 that engage the instrument and register portions 78 and80, respectively. As shown in FIGS. 8 and 10, the obturator 24 of can beadvantageously configured with either a bill shaped dissector tip 94 ora blunt tip 96 at the distal end 74 for separating tissue.

FIGS. 11-13 illustrate another embodiment of the present inventionparticularly useful for endoscopic reduction of bone. The sleeve member22 or 54 can include a flange 98 for engaging tissue along the line ofinsertion and exposing bone. The flange 98 can be formed at the sideedge portions 48 and 50 of the portal 44. As illustrated in FIG. 6, theflange 98 can be formed at the side edge portions 48 and 50 of sleevemember 54 with the flange 98 adjacent instrument portion 78 and spacedapart from register portion 80. A measurement portion 100 can also beused in conjunction with the flange 98 to gauge precisely the reductionor resection of bone. The measurement portion 100 can be formed adjacentside edge portions 48 and 50 that includes a gradient 102 and scale 104.The gradient 102 varies the dimension of the wall 106 forming edgeportions 48 and 50 or the wall 108 of the flange 98. The scale 104 canbe calibrated with the gradient 102 to provide a reference when reducingbone. The measurement portion 100 can be used advantageously in bone orspur removal to a greater precision than previously known in the art,thereby decreasing trauma and speeding recovery.

Referring now to FIGS. 14 through 17, the interchangeable cuttinginstruments provided with a detachable handle are described. In FIGS. 14and 15, a fasciotomy instrument 110 for dividing the plantar fasciaincludes an elongated shaft 112 having opposing proximal and distal ends114 and 116, respectively. The proximal end 114 can have a notch 118configured for use with the locking and release feature of the handle130. The distal end 116 has an active portion 120 configured to improvethe surgical operation of releasing the plantat fascia. The activeportion 120 includes a hook portion 122 extending transversely from theshaft 112, a knife portion 124 along the interior of the hook portion122 and a palpitation extension 126. The knife portion 124 can be formedin a concave shape 128 adaptive to center and cut the plantar fascia.The knife portion 124 also can be formed straight and angled relative tothe elongated shaft 112 to provide for retrograde division from roedialto lateral of the plantar fascia, as shown in FIG. 15. The palpitationextension 126 extends proximally beyond the knife portion 124 and isadapted to hook under and extravasate from the plantar fascia topalpitate the underlying fat pad during division of the plantar fascia.

As shown in FIGS. 16 and 17, the instrument handle 130 includes a shell132, a recess 134 along surface 136 of the shell 132, and a chamber 138.The handle 130 features an activation system 140 for interchanginginstruments with the handle 130 such as when used in the release of theplantar fascia. The activation system 140 includes a release member 142having posts 144 and 146, rocker bar 148 with knob 150 and a spring 152.The release member 142 extends from the chamber 138 through recess 134configured to receive a button 154 attached to the release member 142.The handle 130 can accept insertion of the shaft 112 through hole 156and into engagement with knob 150. Likewise, the spring 152 is biased sothat depression of button 154 causes the rocker bar 148 to pivot anddisengage knob 150 from notch 118 thereby allowing for removal of shaft112. The instrument handle 130 can be formed from plastic or othersuitable materials.

Referring now to FIGS. 18 and 19, an excision instrument 160 useful inperforming a fasciectomy is now described. The excision instrument 160includes an active or operative portion 162 located on the distal end116 of shaft 112. The operative portion 162 has cutting section 164 andgathering section 166. The cutting section 164 has dual laterally spacedknife portions 168 and 170 extending transverse from the shaft 112. Theknife portions 168 and 170 spread slightly at angle 172 for improvingthe cutting of tissue. The palpitation extensions 174 and 176 extendsproximally beyond the knife portions 168 and 170 and is adapted to hookunder and extravasate from the plantar fascia to palpitate theunderlying fat pad during excision. The gathering section 166 hassnagging member 178 that snags and removes cut tissue from the wake ofcutting section 164. The excision instrument 160 can be used with sleevemember 22 or within the instrument portion 78 of member 54.

Referring now to FIGS. 20 and 21a and 21b, a procedure for performingendoscopic heel surgery according to the present invention is described.The patient is placed on the operating table in a prone position havingthe legs extending from the operating table with the feet danglingdownwardly. The foot 180 is locally anesthetized and the skin cleanedfor forming incisions. Alternatively, the knee can be flexed elevatingthe foot 180 with respect to the operating table to minimize impedancefrom the other leg and to manipulate the foot to substantiate therelease of the plantar fascia. The sleeve member 22 or 54 is driven intothe foot 180 from a medial aspect 182 to a lateral aspect 184 of heel186. The foot 180 is comprised of a web of compacted overlapping tissuessuch as, for example, plantar fascia 188 attached to the os calcis 190at a line of insertion 192. At the line of insertion 192, a spur 194 candevelop on the os calcis 190 from the pull and degeneration of planarfascia tissue 188. A fat pad 196 overlies the os calcis 190 and hasnerve branch 198 and vascular branch 200 interwoven therebetween. Theplantar fascia 188 overlies muscles 202 including a flexor digitorumbrevis group 204, abductus hallucis group 206 and abductus digiti minimigroup 208. The sleeve member 22 is positioned distal of the os calcis190 and between the dorsal underlying plantar fascia 188 and superiormuscles 202 avoiding the nerve and vascular branches 198 and 200,respectively. The portal 44 is positioned plantarly and superior to theplantar fascia 188 and distal of the os calcis 190 to provide access andvisualization of the line of insertion 192. Visualization can be madewith a standard 30 degree angulated 4.0 nm arthroscopic camera system222. The portal 44 provides clear assessment of the plantar fascia 188,os calcis 190 at the line of insertion 192. Assessment of the belly andinterface of the muscles 202 such as the abductus hallucis and digitiminimi muscles 206 and 208 and the nerve and vascular branches 198 and200 also can be identified. The camera system 222 is introduced throughthe open end 36 on the roedial aspect 182 of the foot 180. The otheropen end 38 is used as a working portal for the introduction of varioussurgical instruments to operate caudally on the line of insertion 192such as for the transection of the plantat fascia 188 and removal ofspur 194 on the os ealcis 190. Once in positioned adjacent the line ofinsertion 192 of the plantar fascia 188 into the os calcis 190, anendoscope can be inserted into open end 36 and an instrument into theother open end 38. A first and second surgical operation is performed atthe operative site. The obturator 24 is reinserted in the sleeve member22 and this assembly is retracted while forcing plantarly the tip 94 or96 of the obturator 24 again substantiating the complete division of theplantar fascia with the tip 94 or 96 coursing the fat pad 196 underneaththe plantar fascia 188. The operative site is cleaned and layered withcopious amounts of sterile saline. The entry and exit incisions 218 and220 can be sutured closed with a solitary suture and dressed with a drysterile compression dressing after successful performance of the desiredsurgical operations.

As illustrated in FIGS. 14 and 15, the fasciotomy instrument 110 can beused to divide caudally the plantar fascia 188 from the medial aspect182 to lateral aspect 184 with visualization directed via the camerasystem 222. Direction of the medial to lateral division is made in thecaudal approach to avoid damage to the nerve and vascular branches 198and 200 located on the medial aspect 182 of the heel 186. Alternatively,the fasciectomy instrument 160 can be used to excise eaudally a sectionof plantar facial tissue 188 as illustrated in FIGS. 18 and 19.Extravasation of the palpitation extension 126 from the planar fascia188 and fat pad 196 can be felt through the shaft 112 is an indicationof the release of the plantar fascia 188. As was known in conventionalsurgical interventions, the release of the plantar fascia could beexternally substantiated only by palpitation of the dorsal skin orflexure of the foot 180. Thus, the palpitation portion 126 has theadvantage of providing an indication and feel of the release or totaldivision of the plantar fascia 188 during transection. In addition, asthe plantar fascia 188 is a thick tissue, the use of the expanded portal44 has the advantages of enabling visualization of the deep cut apex ofthick tissue.

In order to position sleeve member 22, a location 210 on the roedialaspect 182 of the heel 186 is determined to avoid damage to the nervebranch 198 and vascular branch 200. The location 210 can be determinedusing a non-weight beating lateral radiograph of the foot 180 and themarking system 230 described herein. The lateral radiograph can be usedto measure and triangulate the distance between edge 212 andtuberoscopies 214 and 216 of the os calcis 190. An entry incision 218 ismade on the medial aspect 182 of the heel 186 at the determined location210, as shown in FIG. 21a. The size of the entry incision 218 can vary,for example, incisions ranging from 2 cm to 4 cm. A channel betweentissue and bone can be formed by driving the obturator 24 and the sleevemember 22 assembly through the entry incision 218 from medial to lateraluntil the surgeon can see tenting of the skin on the lateral aspect 184of foot 180, as shown in FIG. 21b. The tip 94 or 96 forms the channel bybluntly separating the plantar fascia 188 from muscles 202 and othersurrounding soft tissue both superiorly and inferiorly. An exit incision220 is made at the location of the tented skin with the assembly passedthrough the foot. The portal 44 should be positioned superior to theplantar fascia 188 and adjacent the os calcis 190 before removing theobturator 24. Thus, an advantage is that the nerve and vascular branches198 and 200 can be visualized and avoided.

As illustrated in FIGS. 22 and 23, the location 210 for insertion of theobturator 24 and the sleeve member 22 assembly can be determined beforesurgery by visualizing using a lateral radiograph or x-ray of the foot180 to identify the location of tuberoscopies 214 and 216 or spur 194such as the distal tubercle margin of the os calcis 190. The marking andinsertion system 230 of the present invention can be use in conjunctionwith the lateral radiograph for precise insertion of the assemblyavoiding damage to neurovascular structures 198 and 200. The system 230includes a heel holding member 232, location member 234 and insertionmember 236. The heel holding member 232 can attach and use the locationmember 234 for non-sterile or non-surgical site use to determinelocation 210 prior to surgery. The heel holding member 232 can thenattach and use the insertion member 236 in the surgical setting. Thelocation member 234 is calibrated correspondingly with the insertionmember 236 so that the location 210 determined by the location member234 has a corresponding location on the insertion member 236. The system230 can be formed from suitable materials such as a radiograph opaqueplastic or the like. The generally L-shaped heel holding member 232 hasa base portion 238 releasably attached to an end portion 240 to keep thefoot in a neutral position such as 90 degrees. The end portion 240 canbe attached to either side of the base portion 238 using thumb screws242 allowing adaptation of either a fight or left foot. Likewise,location member 234 can be attached to the base portion 238 using thumbscrews 242 and allows interchanging the location member 234 for eitherfoot. Both the location member 234 includes a reference scale 244laminated or otherwise disposed within the opaque plastic of thelocation member 234 to superimpose or capture the reference scale 244 onthe lateral radiograph for use in marking the location 2 10 for makingthe entry incision 218. As shown in FIGS. 24a, 24b, 25 and 26, theinsertion member 236 includes a grid portion 246 corresponding to thereference scale 244 for use in inserting a guide wire or pin 248. It isimportant to measure the distance between the edge of the skin on theheel 186 such as the skin abutting the end portion 240 the distal edgeof the os calcis 190. Thus, the coordinates of the determined location210 on the lateral radiograph can be transferred to the grid portion 246to insert guide wire 248. In order to prepare the foot 180 for thelateral radiograph, the foot is positioned in the heel holding member232 with the roedial aspect abutting the location member 234.

As shown in FIGS. 24a and 24b through 26 the location member 234 isinterchanged with the insertion member 236 at the time of surgery. Theinsertion member 236 includes elongated guide tubes 250 arranged andcalibrated to correspond to the grid portion 246. The guide wire 248 isinserted into the guide tube 250 corresponding to location 210. Theelongated guide tubes 250 provide for insertion of the pin 248 from theroedial 182 to lateral 184. Once through the foot, the system 230 usingthe insertion member 236 can be removed from the roedial extension ofguide wire 248 thereby leaving the guide wire in the foot. The obturator24 and sleeve member 24 can use the guide wire 248 as to guide themedial to lateral separation of tissue. Likewise, the bore 86 can beconfigured to receive the guide wire 248 and follow the predefined pathof guide wire 248. Once the sleeve member 24 or 54 is properlypositioned, the guide wire 248 can be removed from the lateral side 184of the foot 180. Thus, the marking and insertion system 230 of thepresent invention can be used advantageously to locate more preciselythe entry incision 218 and avoid damage to neurovascular structures 198and 200, and likewise be used adaptively to insert guide pin 248 throughthe foot 180.

Many modifications and variations of the present invention are possiblein light of the above teachings. Thus, it is to be understood that,within the scope of the appended claims, the invention may be practicedotherwise than as specifically described above.

What is claimed and desired to be secured by Letters Patent of theUnited States is:
 1. A device for use in performing endoscopic surgeryat the interface of tissue and bone, comprising:a tubular sleeve memberhaving open ends and defining a portal opening along the length of saidsleeve, and a slot extending longitudinally along said sleeve, saidportal opening interconnected to said slot intermediate said open ends,said portal opening being circumferentially wider than said slot forforming an expanded surgical site with simultaneous access andvisualization of the interface of tissue and bone.
 2. The device ofclaim 1 wherein said portal opening is defined between two side edges,said device further including flange means integrally attached to one ofsaid side edges and extending outward from said sleeve for exposing abone generally adjacent said sleeve by engaging and moving the tissueaway from the bone.
 3. The device of claim 2 further including measuringmeans for gauging the reduction of the bone to a predetermineddimension, said measuring means being formed by said flange means. 4.The device of claim 1, further including an obturator having a shaftconfigured to pass into said sleeve member, a tip at one end of saidshaft and a stop means at the other end for contactingly engaging saidsleeve member to position said obturator so that said tip extendsoutward from said sleeve when said obturator is inserted into saidsleeve.
 5. The device of claim 4, wherein said tip forms a blunt bulletshape for separating overlapping tissue.
 6. The device of claim 4,wherein said tip form an elongated bill shape for separating overlappingtissues.
 7. A surgical device for use in performing endoscopic surgerywithin a human body comprising:a tubular sleeve adapted to penetrate thehuman body and having opposite open ends, said sleeve defining aninterior passageway extending the length of said sleeve, one of saidopen ends being adapted for the introduction of an endoscope into saidpassageway and the other end being adapted for the introduction ofsurgical instruments into said passageway, said sleeve having a slotformed along its longitudinal length to intersect said interiorpassageway, and a portal opening formed intermediate the length of saidslot and having greater circumferential width than said slot forenabling greater access to the adjacent human body for manipulation ofsaid endoscope and surgical instruments.
 8. The device of claim 7wherein said portal opening is defined between two longitudinallyextending side edges.
 9. The device of claim 7 wherein said portalopening is disposed approximately midpoint along the length of saidsleeve.
 10. The device of claim 7 further including grip means attachedto said sleeve for manipulation and orientation of said sleeve.
 11. Thedevice of claim 10 wherein said grip means is disposed about andattached to one of said open ends, said grip means including a generallydisk shaped collar defining gripping indentations about thecircumferential surface of said collar.
 12. The device of claim 7further including an obturator having a shaft with a distal end and aproximal end, said passageway of said sleeve being configured forslidable insertion and removal of said shaft.
 13. The device of claim 12wherein said obturator defines a central bore extending the length ofsaid obturator, said central bore sized for the passage of a guide wire.14. The device of claim 7 wherein said passageway is formed with agenerally circular transverse cross section.
 15. The device of claim 7wherein said sleeve includes a lower arcuate surface opposite said slotand portal opening, said passageway having a non-circular cross section,said sleeve defining an upper instrument portion of said passagewayhaving a generally circular transverse cross-section and a lowerregister portion interconnected to said instrument portion and definedby said arcuate surface.
 16. The device of claim 7 wherein said portalopening is defined by at least one longitudinally extending side edge,said sleeve also including an outward extending flange connected to saidside edge.
 17. The device of claim 16 wherein a measuring scale isformed on said flange.
 18. The device of claim 7 wherein said slotlongitudinally extends from one of said opposite ends to the other ofsaid opposite ends.
 19. A surgical device for use in performingendoscopic surgery within a human body comprising:a tubular sleeveadapted to penetrate the human body and having opposite open ends, saidsleeve defining an interior passageway extending the length of saidsleeve, one of said open ends being adapted for the introduction of anendoscope into said passageway and the other end being adapted for theintroduction of surgical instruments into said passageway, said sleevehaving a slot formed along its longitudinal length to intersect saidinterior passageway, and a portal opening formed intermediate the lengthof said slot and having greater circumferential width than said slot forenabling greater access to the adjacent human body for manipulation ofsaid endoscope and surgical instruments; and an obturator having a shaftwith a distal end and a proximal end, said passageway of said sleevebeing configured for slidable insertion and removal of said shaft.